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What does SOAP mean?
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What is a Differential Diagnosis?
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Intro Health Records

Intro Health Records Flash Cards Ch. 2

QuestionAnswer
What does SOAP mean? SOAP is an acronym for the four different types of information documented by HCP in a medical note. S is for subjective, O is for objective, A is for assessment, P is for plan.
What is a Differential Diagnosis? The assessment which usually describes the thought process behind a patient's diagnosis and a list of possible causes for the patient's problem, is known as a differential diagnosis.
What is the term for the organism that causes the problem? Pathogen.
What is the anatomic position? This position is a person standing facing forward, arms at the side with palms forward. This is important to note when describing the directions on the human body.
What is the Sagittal Body Plane? It divides the body along a hypothetical plane from right to left.
What are the sections of a Health Record? Chief Complaint, History of Present Illness, Review of Systems, Past Medical History, Past Surgical History, Family History, Social History.
What is a prescription? It is provided by a Medical Professional and it provides directions for a medication. It includes the medications name, Instructions for patient, How much medicine should be given, Refills if any, & the health care professional's signature.
What does NKDA stands for? No Know Drug Allergies.
What does PERRLA stand for? Pupils Equal, Round, and Reactive to Light and Accommodation.
What does EHR stand for? Electronic Health Records.
Created by: ivyt-mg
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